Saturday, January 1, 2011

Oral Contraceptives, Impact and Alternatives

Human females, unlike their male counterparts, are not perpetually fertile. Instead, their reproductive and endocrine systems are directed by the hypothalamus and pituitary to create a complex hormonal process called the menstrual cycle. This menstrual cycle is a precise, methodical process with certain hormone surges at specific times to release an egg, to prepare the uterus for potential implantation and if conception does not occur, to eliminate the ovum and shed the lining of the uterus. In essence, every aspect of the menstruation cycle, conception and contraception is guided by hormonal changes.

When the cycle begins, “the anterior pituitary releases follicle-stimulating hormone (FSH) which promotes the growth of a follicle in the ovary” (Kalat, 2009). The follicle continues to develop the egg. At this point estrogen and estradiol are released as well. When the luteinizing hormone (LH), also from the anterior pituitary, is released and levels of FSH continue to increase, the follicle is stimulated to release the ovum, resulting in ovulation. During this ovulatory period, which lasts for roughly 24 hours, the woman is at her peak fertility and conception can occur. Note also that because sperm are able to survive for several days, a chance of conception exists if sexual intercourse is performed 3-5 days before or after ovulation.

Once the ovum has been released, the body begins to alter the environment of the uterus to prepare for conception. “The remnant of the follicle (now called the corpus luteum) releases the hormone progesterone, which prepares the uterus for the implantation of a fertilized ovum” (Kalat, 2009). Progesterone increases the endometrial lining of the uterus, promoting blood flow to prepare for implantation. The hormone LH is also further inhibited by Progesterone. This part of the cycle is called the Luteal Phase and must be a minimum of nine days long for a woman to conceive and maintain a pregnancy. In many cases, fertility complications are related to a short Luteal Phase. A shortened Luteal Phase is also a post-partum and breastfeeding condition, which has an evolutionary purpose of reducing the chance of conception while the woman is caring for her offspring. After the Luteal Phase, if fertilization has not occurred, all of these hormones begin to decrease and the uterine lining is shed. This is known as menstruation or the period. If fertilization does occur, progesterone and estradiol increase and the processes of implantation and pregnancy begin.

There are several methods available to attempt to avoid or impair the process of conception. The most commonly used method is a compilation of synthetic hormones, known as hormonal contraceptives. Of these, the most popular are oral contraceptives, also known as birth control pills (BCPs). For health reasons, the amount of estrogen was reduced and most BCPS became a combination pill with a variety of hormones and methods of impairing conception. Current oral contraceptives first attempt to suppress ovulation “by interfering with the usual feedback cycle between the ovaries and the pituitary” (Kalat, 2009). They contain synthetic forms of estrogen and progesterone so the body does not try to support and release an ovum. Oral contraceptives are not always successful in preventing ovulation. If ovulation occurs while using oral contraceptives, it is called breakthrough ovulation. “When breakthrough ovulation occurs, then secondary mechanisms operate to prevent clinically recognized pregnancy” (Larimore & Stanford 2000).

These secondary mechanisms include thickening the cervical mucus to make it difficult for sperm to reach the egg and preventing implantation if conception does occur. The final method of combination pills remains controversial for some patients. Larimore and Stanford attempted to study postfertilization effects and concluded that evidence exists that BCPs have high efficacy rates in preventing pregnancy due to the prevention of implantation. Their study, however, was unable to determine a numerical impact. Larimore and Stanford concluded that following the principles of informed consent means “patients who may object to any postfertilization loss should be made aware of this information so that they can give fully informed consent for the use of oral contraceptives” (Larimore & Stanford 2000).

Although some women do choose to avoid oral contraceptives due to the risk of postfertilization loss, more common reasons include avoiding the risks of certain diseases, avoiding interference with fertility and avoiding atrophy or unbalance of the endrocrine system. Recent research published in the New England Journal of Medicine has shed more light on a long-known risk of oral contraceptives called venous thromboembolism (blood clot). The study found that, “currently available oral contraceptives increased the risk of venous thrombosis fivefold compared with non-use” (Vandenbroucke et al., 2009). The level of risk was associated with the particular brand of contraceptive, with some forms having a higher risk than others. Nevertheless, the researchers confirmed that there was “a high risk of venous thrombosis during the first months of oral contraceptive use irrespective of the type of oral contraceptives” (Vadenbroucke et al., 2009).

It should be noted, however, that oral contraceptives have beneficial effects for the very reason that they do interfere or compensate for the hormonal interplay of the female reproductive system. For example, the consistent use of oral contraceptives after laparoscopic excision of ovarian endometriosis, “effectively prevents endometrioma recurrence” (Vercellini et al., 2008). Endometriosis is a painful and debilitating condition that affects the uterine lining. It typically leads to infertility. The cause and cure for endometriosis is not known, but surgery can slow down the condition and help preserve fertility. As the study in the American Journal of Obstretrics and Gynecology showed, oral contraceptives can be a helpful tool in preventing a come back after surgery. Oral contraceptives have also assisted women with a reduction in acne. In one case, researchers completed a randomized, double blind study to compare the effects of a combination BCP on moderate acne. They randomized healthy females ages 14-15 with moderate acne and gave them a BCP for six cycles. The results included a fourfold greater chance of being rated with “clear” or “almost clear” skin compared to the placebo. Researchers concluded, “the 3 mg drsp/20 mcg EE 24/4 regimen COC was significantly more effective than placebo in treating moderate acne vulgaris” (Koltun et al., 2008).

Despite the benefits of long-term use of oral contraceptives, a growing number of healthy women of childbearing age remain concerned about the numerous side effects and possible impact BCPs have on fertility. In previous years, the only other choices women had were to follow a general rule of thumb concept of the cycle using a calendar or counting beads (known as the rhythm method) or completely abstain until they wanted to conceive again. But thanks to advances in science and technology, women now have several accurate, science-based methods to choose from that help them avoid pregnancy, space children and achieve pregnancy without using synthetic hormones.

An internationally recognized, non-hormonal method is the Billings-Ovulation method. It was originally called the Ovulation Method but the World Health Organization added the last name of the doctor, John Billings, in 1978. This method is flexible and can be used by any woman in any situation such as during lactation and irregular cycles. It requires basic skills that women of all ages and education can understand and use. There are nine major studies on the Billings method since the early 1970s that have been conducted around the globe, including America, China, Australia, India and Africa. The studies found a 0%- 2.9% rate of pregnancy while using the method and a 0%-3.9% rate of pregnancy while being trained to use the method.

The most recent study on the Billings Method was conducted in China and found a pregnancy rate of zero when using the method fully trained, or a pregnancy rate of 0.5% during training. (Qian, 1999). When considering that the efficacy rates of perfect use with oral contraceptives ranges from 0.1%-2% and typical use ranges from 3%-5%, the results in China are impressive. The researchers concluded, “the Billings Ovulation Method is well accepted...illiteracy and lower reproductive tract infection are not incompatible with the use of the method” (Qian 1999). They also found, “the use-effectiveness of the Billings Ovulation Method is much higher than that of TCu220c, one of the most popular IUDs used in China” (Qian 1999).

Women who use the Billings Method do not need to alter their hormones; there is no risk of postfertilization loss, no negative impact on fertility and no delay in return to fertility. Furthermore, the method is very inexpensive, utilizing printed charts and needing only a thermometer in its most basic form, although convenient monitors and mini-computers have been invented that electronically capture the data so the woman can easily avoid or achieve pregnancy in the modern world.

A method that is more popular in America is the Creighton Model. This method is based on observing the changes in cervical mucus throughout the menstrual cycle to determine fertility status. The woman then abstains from intercourse or uses barrier methods during the determined ovulatory period. How the signs are observed varies from woman to woman, from the basic process of examining it directly, to high-tech options such as using electronic sensors that automatically detect hormonal surges and record them in a handheld computer. Some women even prefer to perform small cervical exams to visually confirm the location and status of the cervix (as it will close, open and tilt throughout the cycle).

This method has a good track rate of efficacy as well. A study published in the American Journal of Obstetrics and Gynecology found the method to be 98.8% effective at avoiding pregnancy and 24.4% effective when used to achieve pregnancy. (Trussell & Grummer-Strawn, 1991). They also found a high user rate of 78.0% at the 12-month mark which indicates the users were satisfied with the model and continued to use it over other forms of birth control. The researchers concluded, “The Creighton model is an effective method of family planning when used to avoid or achieve pregnancy. However, its effectiveness depends on its being taught by qualified teachers” (Trussell & Grummer-Strawn, 1991). The emphasis on teaching is similar to the impact of teaching on pregnancy rates found with the Billings Ovulation Method.

Requiring a basic education of the anatomy and physiology of the female reproductive system and training on how to observe signs of fertility is the primary disadvantage to non-hormonal methods. Cultural beliefs surrounding female bodies are still very strongly followed, even in developed countries such as America.

Despite increased educational opportunities such as sexual education in public schools and Anatomy and Physiology classes in college, many women and their partners do not start training in these methods with enough basic information about the menstruation cycle, ovulation and how to observe signs of fertility to avoid or achieve pregnancy. This is also observed in the medical fields, where obstetricians and gynecologists remain uncomfortable with the idea of individual awareness of the body. Women who use non-hormonal methods to achieve pregnancy often know their exact conception date, but find this information dismissed or criticized by their primary health care provider during prenatal care. Cultural acceptance and additional education of the female body is needed in this area because although it is easy to understand that non-hormonal methods such as the Billings Ovulation Method and the Creighton Model can be used as tools to avoid or achieve conception, the overall health benefits of using these methods are often overlooked.

Since the woman must have a basic understanding of her anatomy and contribute a small amount of time daily to observing her body, these methods provide an excellent opportunity for early intervention in the case of illness or disease such as cancer, STDs and irregular cycles related to hormonal imbalances. As women continue to use the methods and record and save their daily readings, they create a detailed, accurate case history and can refer to previous menstruation cycles to compare abnormal readings or changes in hormone surges, temperature and cervical mucus. These changes might be normal, indicating thing such as menopause, and can help the woman prepare, or they might signify a disease or illness and alert the woman to obtain professional care from her health provider.

In fact, the Creighton Model gave way to a new women’s health science called NaProTechnology (Natural Procreative Technology) that combines allopathic procedures and science with the observations from the Creighton Model to help women with their fertility and reproductive-related health issues. (Hilgers 2004). The many benefits of non-hormonal methods such as their efficacy both in avoiding and achieving conception, the emphasis on giving women a basic understanding of anatomy and science, the low cost of materials and their ability to help detect changes and abnormalities makes them an impressive choice over oral contraceptives. For women concerned about the risks, costs and potential impairment or delay of fertility from using oral contraceptives, these non-hormonal methods remain a satisfactory alternative and should receive more attention and research in the issue of women’s health.

3 comments:

I cannot praise NAPRO enough. All I can tell you is that just a few months ago we were told we'd need ICSI by a private fertility clinic. Thankfully, they were wrong. ;) PLEASE - anyone who has problems wtih their cycles, hormonal issues, fertility issues, (INCLUDING male fertility issues), or simply anyone who wants to avoid pregnancy or understand their body better - NAPRO is wonderful. And they take the time to care. No, I'm not on commission, but I AM a convert! http://www.fertilitycare.net/

We just started using the Fertility Awareness Method as a means to postpone pregnancy. I'm on my first cycle and love it! I feel so much better than when I was on the pill. I definately will not ever take the pill again.